Faktor Risiko Jantung 2013

8/10/2019 Faktor Risiko Jantung 2013

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Faktor Risiko Penyakit Jantung

Lisa Kurnia Sari


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Cardiovascular Disease

Coronary heart disease (CHD) manifested bymyocardial infarction (MI), angina pectoris,heart failure (HF), and coronary death

Cerebrovascular disease manifested by strokeand transient ischemic attack

Peripheral arterial disease manifested by

intermittent claudication Aortic atherosclerosis and thoracic or

abdominal aortic aneurysm


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The lifetime risk for individuals at age 40 was

49 percent in men and 32 percent in women.

Even those who were free from disease at age

70 had a lifetime risk of 35 percent and 24

percent in men and women, respectively.


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Non Modifiable Risk Factors:

- Age

- Family History- Sex


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INTERHEART study

Nine modifiable risk factors:

smoking, dyslipidemia, hypertension,

diabetes, abdominal obesity, psychosocial

factors, daily consumption of fruits and

vegetables, regular alcohol consumption, and

regular physical activity.


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Atherosclerosis is responsible for almost all

cases of CHD.

This insidious process begins with fatty streaks

that are first seen in adolescence; these

lesions progress into plaques in early

adulthood, and culminate in thrombotic

occlusions and coronary events in middle ageand later life.


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Hypothesis for the origins of the

metabolic syndrome


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Abnormalities included in

the metabolic syndrome


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Mechanisms linking the metabolic

syndrome and CV disease


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How to Assess Risk?

Assess risk factors:

CHD or CHD risk equivalent (regardless of number ofrisk factors) using NCEP ATP III

2 risk factors with no CHD & no CHD risk equivalent

using NECP ATP III major risk factors that modify LDLgoals

If 2 risk factors & no CHD or CHD riskequivalent:

Assess global CHD risk by Framingham Point Score


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Clinical CHD Carotid artery

disease

Peripheral

arterial disease

Abnormal

aortic

aneurysm

DM

Myocardial ischemia(angina) Stroke history Claudication Present Present

Myocardial infarction Transient

ischemic attack

history

ABI 50%

CABG

Prior unstable angina


12/70http://www.nhlbi.nih.gov


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Clinical Criteria for Diagnosis


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Metabolic Syndrome increase the risk of anycardiovascular events, coronary events, and

cerebrovascular events among elderly individual.


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47.000.000 adults had (23%)

metabolic syndrome in US

0

5

10

15

20

25

30

35

40

45

50Men (n=4265)

Women (n=4559)

Age, Year

Ford ES et al. JAMA 2002;287:356-9

Prevalence(%

)

20-29 40-4930-39 50-59 60-69 70

Prevalence of the Metabolic Syndrome Among US Adults :Findings From the Third National Health and Nutrition Examination Survey


19/70Cameron AJ. EndocrinolMetabClin N Am 2004;33:351-75


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Special Consideration

Comorbid disease

Drug side effects

Poly-pharmacy Patient adherence

Drug preference

Complication Social support


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NON PHARMACOLOGIC TREATMENT


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Non Pharmacologic Treatment

Lifestyle modification

Diet

Physical Exercise

Smoking Cessation

Stress Reduction

Weight Control

Behaviour Change

Nutritional Genomics


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Some moderate-intensity physical activities

Daily life Sports

Washing car, 4560 min Walking 3 mph, 35 min Less vigorous

Washing windows or floors,

4560 min

Bicycling 10 mph, 30 min

Gardening, 3045 min Dancing, 30 min

Raking leaves, 30 min Water aerobics, 30 min

Swimming, 20 min

Jogging 1 mile, 15 min More vigorous

150 calories of energy per day

NHLBI. www.nhlbi.nih.gov.


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At least 30 minutes ofmoderate-intensity exerciseon most (and preferably) all

days of the week Moderate intensity: 50-60%

of maximum capacitybriskwalk 15-20 min per mile

(Exercise Zonebased onmaks HR)

Exercise plan may require modification for certain patients

with complications NHLBI. www.nhlbi.nih.gov.


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Zone 50-60% : exercise and daily activity

Zone 60-70% : weight control

Zone 70-80% : aerobic and cardiovascular Zone 80-100% : competition

If older than 40 y.o : 208(0,7 X age)

The goal of physical activity in management of

DM is increasing Basal Metabolic Rate (BMR)

American College of Sport Medicine


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Food Recomendation

Eat Less of These Eat More of These

Avocado, Nuts, Olives, Oils unsaturated, Fish,

Chicken lean, Fruits, Vegetables

Coconut, Margarine/butter, Cheese,

Oils/fats rich in saturated fat


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Possible Benefits From Other Therapies

Therapy Result

Soluble fiber in diet (28 g/d) (oat bran,

fruit, and vegetables)

Soy protein (2030 g/d)

Stanol esters (1.54 g/d) (inhibit

cholesterol absorption)

Fish oils (39 g/d)

(n-3 fatty acids)

LDL-C 1% to 10%

LDL-C 5% to 7%

LDL-C 10% to 15%

Triglycerides 25% to 35%

Jones PJ. Curr Atheroscler Rep.1999;1:230-235.

Lichtenstein AH. Curr Atheroscler Rep.1999;1:210-214.

Rambjor GS et al. Lipids.1996;31:S45-S49.

Ripsin CM et al.JAMA.1992;267:3317-3325.


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PHARMACOLOGIC INTERVENTION


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OBESITY


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GLUCOSE CONTROL


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PERKENI, 2011


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PERKENI, 2011


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PERKENI, 2011


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BLOOD PRESSURE CONTROL


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DYSLIPIDEMIA


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How to choose the treatment ?


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Effect of Lipid-modifying Therapies

Therapy TC LDL HDL TG Patienttolerability

Bile acid

sequestrants7-10% 10-18% 3% Neutral or Poor

Nicotinic acid 10-20% 10-20% 14-35% 30-70%Poor to

reasonable

Fibrates

(gemfibrozil)19% 4-21% 11-13% 30% Good

Statins* 19-37% 25-50% 4-12% 14-29% Good

Ezetimibe 13% 18% 1% 9% Good

Recent Coronary prevention Studies


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Recent Coronary prevention Studies

with Statin

Study Drug N Duration(yr)

Main findings

HPS 1 Simvastatin 20536 5

13% total mortality

27% coronary events*

25% stroke

24% any major vascular event

PROSPER 2 Pravastatin 5804 319% coronary events*

Stroke events unaffected

ALLHAT-LLT 3 Pravastatin 10355 5Total mortality unaffected

Coronary events* unaffected

ASCOT-LLA4 Atorvastatin 10305 3.3

13% total mortality (NS)

36% coronary events*

27% stroke

1. Lancet 2002;360:7-22; 2. Lancet 2002;360:1623-30; 3. JAMA 2002;288:2998-3007;

4. Lancet 2003;361:1149-58.


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Specific Dyslipidemias: Elevated Triglycerides

Management of Very High Triglycerides

(>500 mg/dl)

Goal of therapy: Prevent acute pancreatitis

Very low fat diets (< 15% of caloric intake)

Triglyceride-lowering drug usually required (fibrate or nicotinic

acid)

Reduce triglycerides beforelowering LDL

If a patient also has a high risk for a cardiovascular event, LDL-

lowering therapy should be considered.


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Clinical Reviews


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Lipophilicity vs. Hydrophilicity

Lipophilic statins penetrate muscle more easily than hydrophilic statins

Associated with a higher incidence of adverse effects, particularly myopathy,

although reports of muscle toxicity, including rhabdomyolisis have been

reported with allstatins.1

Simvastatin is the most lipophilic statinlovastatinatorvastatin.

Hydrophilic statins include pravastatin and fluvastatin.

Rosuvastatin is relatively hydrophilic. 3(p.139)

Although hydrophilic statins have a lower association with adverse effects,

they generally require higher dosing to be efficaciouswith the exception of

rosuvastin.3 Higher doses, in turn, may be associated with adverse effects.
http://www.pogoe.org/ask/statinshttp://www.pogoe.org/ask/statinshttp://www.pogoe.org/ask/statinshttp://www.pogoe.org/ask/statinshttp://www.pogoe.org/ask/statinshttp://www.pogoe.org/ask/statins


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Protein-binding

Protein binding also plays a role in the

potential for adverse effects of statins.

Statins other than pravastatin are highlyprotein bound.

Decreases in serum protein levels, often seen

in frail older adults may result in higherconcentrationsand higher toxicity.


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Statin in Elderly

Older chronological age in and of itself should not exclude

patients from receiving therapy, especially if an otherwise

healthy older patients remaining years of life may benefit

from prevention of the morbidity associated with a coronary

event.

Kidney function should be tested before treatment. There is

an increase risk of myopathy when GFR decreased.

Elderly with AMIScandinavian Simvastatin Survival Study

CARE (Cholesterol and Recurrent Events) Trial

LIPID (Long Term Intervention with Pravastatin in Ischemic Disease) Trial

HPS (Heart Protection Study)

PROSPER (Prospective Study of Pravastatin in the Elderly at Risk)

NKF Recommendations


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NKF Recommendations

for Statin Dose Adjustment in CKD

National Kidney Foundation.Am J Kidney Dis. 2007;49(suppl 2):S1-S180

Use doses >20 mg/day cautiously

in patients with GFR 40 mg in these patients

No adjustmentFluvastatin

No adjustmentNo adjustmentNo adjustmentPravastatin

Starting dose 5 mg daily in patients withsevere kidney disease

No adjustmentSimvastatin

Starting dose 5 mg and NOT to exceed 10 mg

in patients with GFR


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How to Titrate dose or switch to

another statin

Some adverse effects associated with statin drugs are dosage-related(eg,

myopathy/rhabdomyolysis), and with some statins, liver dysfunction may

increase with increased dosage

If statin tolerability is a concern, a combination of drugs at lower dosages

may be effective


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Follow-up and Monitoring

Reassessing patients lipid status 6 weeks after therapyinitiation and again at 6-week intervals until the treatment

goal is achieved. Thereafter, that patients be tested at 6- to 12-month

intervals.

The specific interval should depend on patient adherenceto therapy and lipid profile consistency.

If adherence is a concern or the lipid profile is unstable, thepatient will probably benefit from biannual assessment


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More frequent lipid status evaluation

Deterioration of diabetes control.

The use of a new drug known to affect lipidlevels.

Progression of atherothrombotic disease. Considerable weight gain.

An unexpected adverse change in any lipidparameter.

Development of a new CAD risk factor. Convincing new clinical trial evidence or

guidelines that suggest stricter lipid goals.


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Follow-Up Recomendation

Lipids 6 weeks after start / change of dose (levels reach steady state within 6

weeks of start/change of medication)

Long-term follow-up every 6-12 months

AST / ALT (0.53% incidence)

Get baseline Use with caution if AST/ALT > 3 x normal

At 12 weeks after initiation or change in dose (FDA)

CK (< 0.5% incidence) Get baseline

Check only if symptomatic with myalgias (ATP III guideline)

More attention in elderly patient


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Myopathy Recomendation


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TAKE HOME MESSAGES

Metabolic Syndrome increase the risk of anycardiovascular events, coronary events, andcerebrovascular events among elderly.

The purpose of metabolic syndrometreatment in elderly is to reduce mortality andmorbidity.

The target of metabolic syndrome treatmentshould be adjusted individually, based onpatients condition.


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Thank You

Thank you to dr. Bowo Pramono, SpPD-KEMD, dr. Lutfan, SpPD-KEMD,

dr. Hemi Sinorita, SpPD-KEMD, dr. Robikhul Iksan, M.Kes., SpPD-KEMD,

for the permission to use some of the powerpoint slides.

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Faktor Risiko Jantung 2013

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